Get Wi Dhs F-00059 2016-2025

Filling out the WI DHS F-00059 form is an essential step for outpatient mental health clinics seeking certification in adherence to state regulations. This guide provides user-friendly, step-by-step instructions to help you navigate the online application process effectively.

Follow the steps to complete your online application.

1. Press the ‘Get Form’ button to acquire the form and open it in the online editor.
2. Fill in the date when the application is completed. Ensure accuracy in all sections.
3. Enter the facility name and certification number. This information is critical for identification purposes.
4. Provide the main office's street address, city, state, and zip code. Double-check for typographical errors.
5. Include the mailing address for the main office, if different from the physical address, following the same format as above.
6. Identify the contact person for the clinic, along with their telephone number, fax number, and email address.
7. Specify if the contact email can be published in the provider directory by marking ‘Yes’ or ‘No.’
8. Provide details about any additional service locations by attaching the DQA form F-00191 if applicable.
9. Select your clinic's accreditation status by checking the appropriate box and providing the accreditation end date.
10. Review the attestation statement, confirming the accuracy of all information before signing as the clinic administrator.
11. Initial to agree to the optional electronic transmission for communications, entering your official email address.
12. Complete the staffing requirements section by answering questions regarding staff qualifications and the clinic administrator's role.
13. Provide detailed information about any other required sections, such as clinical supervision policies and treatment plans.
14. Once all fields are completed, save changes, download, print, or share the application as necessary.

Begin your application process for the WI DHS F-00059 online today!